2016-17 AED Grant Application Form.pub
All 2016-2017 grant applications in support of the La.-Miss.-W.Tenn. District’s Major Emphasis Project - placing Automated External Defibrillators (AEDs) in Schools - must be submitted to the La.-Miss.-W.Tenn. Kiwanis District Foundation on this form. Supplemental sheets may be used, if necessary. This Grant Application is submitted by the Kiwanis Club of:
The La.-Miss.-
W.Tenn. Kiwanis District Foundation offers $500 grants to assist clubs with the District Project, i.e., placing AEDs into schools. Clubs wishing to submit a grant application for a facility other than a school may also use this form. Kiwanis Clubs may only apply for one AED Grant per Kiwanis Year.
The La.-Miss.-
W.Tenn. District Foundation Board of Directors will accept 2016-2017 AED Grant Applications until July 1, 2016, or until budgeted funding is depleted.
NOTE: Incomplete
applications may be returned and delay the grant approval process.
For assistance with the donation of an Automated External Defibrillator (AED) to the following school:
Primary Club Contact for this project: Name: Phone:
E-Mail:
I , Club President, hereby certify that the following criteria have been met by our Kiwanis Club, and respectfully request the La.-Miss.-W.Tenn. Kiwanis District Foundation Board approve this AED Grant Application.
□
By official action of our club’s Board of Directors, approval to submit this request was taken at the Board Meeting held on ______________.
□
Our Kiwanis Club is in good standing with the La.-Miss.-W.Tenn. Kiwanis District Foundation, having contributed at least $5 per member to the 2016-2017 Annual Club Giving Campaign, on _____________, in the amount of $_________. (Check # ______)
An AED is being provided to the school (named above) as stated below:
□
An AED was purchased on ____________, for the school. A copy of the invoice and proof of payment is enclosed with this application for verification for reimbursement.
OR
□
An AED will be ordered for this school within the next 90 days. A copy of the invoice or proof of payment will then be forwarded to the La.-Miss.-W.Tenn. Kiwanis District Foundation for reimbursement.
For District Foundation use only. Do not write in this box!
AED Grant Application Received: ___/ ___/20____. Date of Decision: ___/ ___/20____. Date of Notification: ___/ ___/20____. Foundation Board Decision:
NOTE: BOTH SIGNATURES REQUIRED: 2016-2017 President: Print Name:
Signature:
Date: ____________
Daytime Phone: __________________________
Approved Not approved
2016-2017 Secretary:
Grant Committee Member contact:
Print Name:
Signature:
Date: ____________
_________________________
Daytime Phone: __________________________
Kiwanis District Office 5319‐B Didesse Drive Baton Rouge, LA 70808‐6401 (225)769‐9233 [email protected]
The La.-Miss.-
W.Tenn. Kiwanis District Foundation offers $500 grants to assist clubs with the District Project, i.e., placing AEDs into schools. Clubs wishing to submit a grant application for a facility other than a school may also use this form. Kiwanis Clubs may only apply for one AED Grant per Kiwanis Year.
The La.-Miss.-
W.Tenn. District Foundation Board of Directors will accept 2016-2017 AED Grant Applications until July 1, 2016, or until budgeted funding is depleted.
NOTE: Incomplete
applications may be returned and delay the grant approval process.
For assistance with the donation of an Automated External Defibrillator (AED) to the following school:
Primary Club Contact for this project: Name: Phone:
E-Mail:
I , Club President, hereby certify that the following criteria have been met by our Kiwanis Club, and respectfully request the La.-Miss.-W.Tenn. Kiwanis District Foundation Board approve this AED Grant Application.
□
By official action of our club’s Board of Directors, approval to submit this request was taken at the Board Meeting held on ______________.
□
Our Kiwanis Club is in good standing with the La.-Miss.-W.Tenn. Kiwanis District Foundation, having contributed at least $5 per member to the 2016-2017 Annual Club Giving Campaign, on _____________, in the amount of $_________. (Check # ______)
An AED is being provided to the school (named above) as stated below:
□
An AED was purchased on ____________, for the school. A copy of the invoice and proof of payment is enclosed with this application for verification for reimbursement.
OR
□
An AED will be ordered for this school within the next 90 days. A copy of the invoice or proof of payment will then be forwarded to the La.-Miss.-W.Tenn. Kiwanis District Foundation for reimbursement.
For District Foundation use only. Do not write in this box!
AED Grant Application Received: ___/ ___/20____. Date of Decision: ___/ ___/20____. Date of Notification: ___/ ___/20____. Foundation Board Decision:
NOTE: BOTH SIGNATURES REQUIRED: 2016-2017 President: Print Name:
Signature:
Date: ____________
Daytime Phone: __________________________
Approved Not approved
2016-2017 Secretary:
Grant Committee Member contact:
Print Name:
Signature:
Date: ____________
_________________________
Daytime Phone: __________________________
Kiwanis District Office 5319‐B Didesse Drive Baton Rouge, LA 70808‐6401 (225)769‐9233 [email protected]
